WASHINGTON — Better communication is the key to better asthma management, said an expert in pediatric asthma, who offered a few tips on improving communication with patients and parents at a meeting sponsored by the American Academy of Pediatrics.
The bottom line is that it is the family who manages a child's asthma on a daily basis. “You're not going to go home and manage your patient's asthma. It's really the family that's going to do a lot of the management,” said Dr. Michael Cabana, director of general pediatrics at the University of California, San Francisco and UCSF Children's Hospital.
However, the best management plan won't work if the family doesn't adhere to the regimen, and adherence is closely linked to clinician communication and patient education, he said.
Research indicates that there are no good predictors of family/patient adherence to asthma management plans. “It's hard to predict which parents are going to be adherent to any specific recommendation,” said Dr. Cabana.
Study results have consistently shown that less than 50% of patients adhere to daily medication regimens. In light of the difficulty in predicting which half of patients will adhere to their asthma regimens, all patients should be educated to ensure compliance, said Dr. Cabana. Communicating well and providing education are as important as prescribing the right medication.
Dr. Cabana and his colleagues recently published the results of a nationwide, randomized controlled trial that demonstrated that patients whose physicians participated in a program to enhance their communication skills had better asthma outcomes after 1 year (Pediatrics 2006;117:2149–57).
According to one model, a patient's (or parent's) beliefs influence willingness to follow preventive or therapeutic recommendations. Families have to believe that their children are susceptible to asthma, that asthma is a serious health threat to their children, that the benefits of the asthma management plan outweigh the costs, and that they can carry out the components of the asthma plan confidently.
In terms of susceptibility, some families may resist the diagnosis of asthma, believing instead that the disease is feigned. Resisting the diagnosis reduces the likelihood that the family will follow the treatment plan.
With respect to the perceived seriousness of the disease, if the family thinks asthma is not serious, they are less likely to follow the treatment plan. On the other hand, if the family overestimates the seriousness of the asthma, they may follow the plan but also may prevent the child from taking part in normal physical activities.
Although the benefits of therapy are clear to physicians, these benefits may be unclear to patients or irrelevant to their personal goals. However, the perceived costs of therapy are often obvious to families: Therapy represents a possible financial burden and harm to the child from medications; also, therapy is time consuming and difficult to carry out.
Fears about asthma medications among families are not trivial. Roughly 40% believe that these medications are addictive; 36% believe these medications are not safe for long-term use; and almost 60% believe that regular use will reduce effectiveness, said Dr. Cabana. In addition, many families lack confidence that they can manage an asthma attack at home.
But there is help. It comes in the form of specific communication techniques that are repeated and consistently used and that have been shown to enhance physician communication with patients as well as outcomes for patients:
▸ Nonverbal attentiveness, addressing immediate concerns, and giving reassuring messages all serve to relax and reassure patients so that they pay attention to what is being said.
▸ Interactive conversations and eliciting underlying fears help to improve the exchange of ideas and feelings and to gather information needed for diagnosis and treatment decisions.
▸ Tailoring messages, planning for decision making, and goal setting prepare patients to carry out the treatment at home.
▸ Nonverbal encouragement and verbal praise help build the self-confidence necessary to carry out the plan.
There also are several basic asthma concepts that must be understood by patients, if they are to use therapies successfully and control asthma triggers.
“I try to limit it to two or three key messages per visit,” said Dr. Cabana, adding that he distributes and reinforces the messages over time through discussions and handouts.
The topics include:
▸ What happens during an asthma attack.
▸ How medicines work.
▸ How to take the medicines.
▸ How to respond to changes in asthma severity.
▸ Medication safety.
▸ Goals of therapy.
▸ Criteria for successful treatment.
▸ Managing asthma at school.
▸ Identifying and avoiding triggers.